Refeeding Syndrome: Recognize and Respond Essay (Article)

Refeeding syndrome (RFS) is an acute alteration in fluid and electrolyte equilibrium that occurs in underfed patients following nutritional assistance (Yantis & Velander, 2009). Parenteral nutrition is the most common cause of RFS although enteral nutrition and oral administration of I.V fluids with dextrose can also cause it. The initial case of RFS was observed after the Second World War when feeding of malnourished casualties led to cardiac and neurologic malfunction (Rio et al., 2013). Presently, most cases of RFS arise in hospitalized patients with a large proportion of the patients showing electrolyte imbalance. RFS is characterized by reduced concentrations of magnesium, potassium or phosphorus (Mehanna, Moledina, & Travis, 2008). These symptoms manifest within the first 72 hours after initiation of feeding and can continue for the subsequent two to seven days (Yantis & Velander, 2009). Cardiac problems happen in the initial 48 hours while neurologic disorders occur later. Any malnourished individual is at risk of RFS. However, persistent alcoholism, rapid weight loss and prolonged starvation increase the risk of RFS.

Pathophysiology of Refeeding Syndrome

The body has a preference for glucose (which comes from the ingestion of carbohydrates) as the key source of fuel. Prolonged starvation depletes glucose reserves causing the body to move to the breakdown of protein and fat for energy. Consequently, the quantity of insulin falls because of the reduced availability of carbohydrates. A steady reduction of cellular and muscle mass then arises causing the degeneration of essential organs such as the heart, intestines and liver. Therefore, cardiac and respiratory performances weaken leading to a slow metabolic rate. Nutritional support (refeeding) can be attempted to restore the body’s activities. However, if done aggressively such as in parenteral feeding, refeeding can cause adverse consequences mainly because of the alteration in the production of insulin. Restoring glucose in the body increases the amount of insulin, which promotes cellular uptake of glucose alongside electrolytes such as phosphate, potassium and magnesium. This causes hypophosphatemia, hypokalemia and hypomagnesemia (Khan et al., 2011).

Nursing and Medical Management of Refeeding Syndrome

Nurses must work together with dietitians, health care providers and pharmacists to prevent RFS (Yantis & Velander, 2009). Nurses ought to recognize patients at risk from their pre admission medical history and promptly detect the signs of RFS. This involves checking serum electrolyte concentrations and making certain that they are normal ahead of commencing nutritional support. If abnormal, the electrolyte levels ought to be corrected without delay. The administration of phosphate to anorexia nervosa patients prevents RFS (Rio et al., 2013). Blood pressure and pulse rate also need to be checked. It is important to restore blood volume, but care is required to prevent fluid overload. In addition, it is mandatory that the refeeding rate is closely supervised and should begin with a low caloric intake that is gradually increased as the body adjusts to food. Patients are advised to take small food portions that are low in glucose especially protein-rich foods. The initial three days of refeeding are crucial, and a nurse needs to monitor the electrolyte levels during this time. Vitamin concentrations (especially thiamine) also require checking to prevent confusion and ataxia. Hyperglycemia can be prevented by monitoring the blood glucose and ensuring that it does not exceed 200 mg/dL (Yantis & Velander, 2009). Since RFS patients can develop neurological and cognitive changes, fall risk measures need to be established to ensure the safety of the patients.

Application of Information to Professional Nursing Practice

This article gives the guidelines to follow in the management of RFS patients. It emphasizes nurses’ vigilance as the major way of preventing and monitoring RFS. It urges teamwork between nurses and other health care providers for the well-being of RFS patients. Timing is vital in preventing RFS. This paper gives the time intervals within which nurses should monitor the electrolyte levels of their patients. Therefore, nurses ought to follow these guidelines to prevent the adverse effects of RFS.

Questions

1. RFS is most often associated with parenteral nutrition (A).
2. Electrolyte disturbances with rapid initiation of refeeding usually include decreased potassium (B).
3. After rapid initiation of refeeding, cardiac complications can develop as early as 24 to 48 hours (C).
4. The statement about RFS that is incorrect is that RFS occurs only in people with dramatic recent weight loss (D).
5. At particular risk for malnutrition is a patient who has chronic alcoholism (C).
6. The body’s preferred fuel is glucose (B).
7. During malnutrition, all of the following occur during fat and protein catabolism except cardiac hypertrophy (A).
8. The statement that is correct about malnourished patients is that patients can be overweight or obese (D).
9. The driving force behind the electrolyte shift during aggressive nutritional support is the increase in insulin secretion (A).
10. Respiratory failure during refeeding is generally caused by severe hypophosphatemia (C).
11. The blood test that is not used to evaluate the patient’s visceral protein status is hemoglobin (B).
12. The correct statement about fluid balance while refeeding a severely malnourished patient is that fluid intake may need to be restricted (A).
13. The recommended rate for the initial refeeding of an adult is about 15 to 20 kcal/kg/day (B).
14. During phosphorus administration, monitor the patient for tetany (A).
15. As a general rule, malnourished patients at risk for RFS should receive thiamine supplements (C).
16. The correct statement about the neurological complications of RFS is that patients should be placed on fall risk precautions (D).
17. Hematologic signs and symptoms of RFS include all of the following except thrombocytosis (D).
18. Insulin secretion affects electrolytes because it uses decreased serum magnesium (B).

References

Khan, L. U. R., Ahmed, J., Khan, S., & MacFie, J. (2011). Refeeding syndrome: A literature review. Gastroenterology Research and Practice, 2011(2011), 1-6.

Mehanna, H. M., Moledina, J., & Travis, J. J. (2008). Refeeding syndrome: What it is, and how to prevent and treat it. BMJ, 2008(336), 1495-1498.

Rio, A., Whelan, K., Goff, L., Reidlinger, D. P., & Smeeton, N. (2013). Occurrence of refeeding syndrome in adults started on artificial nutrition support: Prospective cohort study. BMJ Open, 3(e002173), 1-9.

Yantis, M., & Velander, R. (2009). How to recognize and respond to refeeding syndrome. Nursing Critical Care, 4(3), 14-20. Web.